Clalit Research Institute April 2014 Real-life data analysis at the Clalit Research Institute: Data-driven policy in action Israel has benchmarked high in global NCD mortality and complications measures. Over the last two decades. These clinical improvements were supported by wide early adoption of Electronic Health Records throughout the country, all tiers of community care. Clalit is Israel's largest healthcare organization which serves as insurer/payer and integrated care provider for over half of the Israeli population – over 4.3 million people. Clalit has been leading innovative interventions using clinical data to drive people-centered targeted and effective care models, for NCD prevention and control. In its strategic plans, Clalit aims to perform a paradigm shift to properly deal with these challenges, transforming the healthcare system to one which can bridge the silos of care provision in a patient-centered approach, move from reactive therapeutic to proactive preventive care, and abandon our paternalistic narrative to a participatory and engaging patient-physician relationship. We at Clalit believe that a key driving force and a pre-requisite for these changes is the availability and intelligent integrated use of EHR-based clinical data, and have been practicing innovative utilization of this data for quite a few years with successful measurable outcomes. Many of the unique innovative interventions introduced by Clalit are data-driven, made possible by real-time data provided to physicians and nurses, in an actionable, decision- supporting format. Clalit has a 100% (single software) Electronic Health Records coverage of ambulatory and hospital care, with an aggregated data warehouse that received feeds from both, on our 4.3 million members, for well over 1.5 decades. This data included detailed and full demographic (i.e. place of birth of person and parents), diagnoses (both EMRs and Claims driven), measures (i.e. as BMI, blood pressure), other clinical data (full labs, imaging), patient reported (i.e. smoking status and willingness to quite smoking), cost (pricelist and real-life mothly cost per patient), drugs (both prescription and dispensing data), and administrative data (health services consumption). This is augmented in Clalit by the largest ongoing patient experiences survey performed in Israel, ongoing all year long to a very large patient sample, and an increasing amount of data becoming available through Clalit's patient portal and Personal Health Record (PHR). Quality of care, patient experiences and financial benchmarks are all part of an online balanced scorecard system available to all managers at all levels of the organization. In 2010, Clalit launched its Research Institute, which now holds over 15 professionals of multidisciplinary qualifications – top notch clinicians, epidemiologists, biostatisticians, IT experts, algorithm specialists and public health experts. The institute associates gained invaluable experience in mining and interpreting the organizational database, and creating tools introduced into policy and medical practice. These tools allowed for implementing 1 Arlozorov Street, Tel Aviv 62098 Tel: 972-3-69235800 Fax: 972-3-
Clalit Research Institute innovative clinical interventions to tackle key health issues such as reducing healthcare disparities, preventing avoidable readmissions, tackling inadequate treatment adherence, assessing the impact of multi-morbidity, improving control of key chronic diseases, performing comparative effectiveness real-life studies and using predictive modeling and advanced analytics to allow targeted care in high risk groups. A few recent examples of the different types of studies perform at the institute would include our recent study have afforded new insights into the methodology of assessing medication adherence, and has shown that previous studies looking at statin non-adherence have likely massively underestimated the extent and impact of inadequate adherence to this therapeutic group, as it ignoring prescription data and only used dispensing data. Other studies allowed us to identify subgroups at uniquely high risk for GFR (kidney function) deterioration, and begin a directed preventive program at this group. We have shown, through our data, a J-shaped association between serum vitamin D concentration and major CVD outcomes, a study that was of high impact to recent policymaking globally. Two recent compelling case studies for large scale policy change based on our research are that of reducing readmissions in Clalit, and one of reducing disparities in key quality indicators. Briefly - a comprehensive program to reduce readmissions rate on the entire population of 500,000 elderly members (100% of elderly members), was introduced in July 2012. which used a set of real-time data tools to identify upon admission patients at high risk of readmission, interoperable system for online data transfer from GP record to hospital view, embedded discharge planning tools for direct hospital-clinic nurse-nurse communication, alert to clinic on patient discharge and structured discharged patient telephone interview, and enhanced home care teams, as well as a set of unified on-line unified process and outcome indicators. The results of these efforts were evident within a year of implementation - baseline integrated infrastructure allowed readmission rates that were lower compared with internationally available benchmarks. Rate of absent GP-clinic contact within a week of discharge has dropped following a year of the program implementation from 37% to 13%, with a 5% further reduction in elderly readmission. A second example to transforming care through data, an organization-wide quality-of-care disparity reduction program focused at >400,000 least-affluent members (lowest 10% of entire Clalit population), was implemented in 2009-2011. 400,000 members, of low socio- economic status localities with low achievements in key quality indicators were selected using a composite measure of the most disparity-associated quality measures including metabolic disease control, vaccination and cancer early detection compliance. A combined top-down and bottom-up approach was used to direct culturally-competent care with emphasis on local community involvement and enhancing multi-sectorial teamwork. A set of dedicated indicators was available on-line in each clinic to monitor and direct improvement efforts. This disparity reduction program achieved a complete closure of the differences between the low SES groups in Clalit and the rest of the population in preventive medicine indicators (such as vaccination and cancer screening), as well as a reduction of 60% in the difference in composite disparity-associated quality indicators score between the selected 2 Arlozorov Street, Tel Aviv 62098 Tel: 972-3-69235800 Fax: 972-3-
Clalit Research Institute least-affluent members and their district averages. In these years, a sharper decline in Acute Myocardial infarction rates was witnessed in the low-SES groups as compared with the population average. Some conclusion can be drawn from of these brief case studies, that integrated data systems allow a wide potential for implementing innovations in care integration. Integrated data allows for innovative patient selection approach, in-depth program planning, real-time implementation support IT tools and real-time monitoring of intervention outcomes thus allowing multi-level effective intervention management. We continuously increase our research capacity through our rich network of collaborative efforts with leading academic entities worldwide as well as the major global health industry players. These collaborations allow further innovative work on our unique databases, for the benefit of our patients and patients worldwide. For further details please contact the Clalit Research Institute: research@clalit.org.il 3 Arlozorov Street, Tel Aviv 62098 Tel: 972-3-69235800 Fax: 972-3-
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